tachycardia question

[jimihendrix]

In the long-term care facility where I work with pt's with profound disabilities, I had a pediatric resident with a hx of frequent chest infections. Our normal practice there has been to call the MD if none in house, and antibiotics would be ordered. Last week, this girl started up, as I have seen her many times before. HR 130's, RR 30's, T 38, congested. Sats dropped to 80's, I started O2, increased to 5 L, and brought her sats up to 92%. Eventually transferred to ER about 5 a.m., and now I am in big trouble because I was asked why I didn't transfer her 3 hours sooner. There has been a change in our DON recently, and she is really gung-ho about cleaning up the quality of nursing in our facility. Now all of a sudden, I am being investigated. I was told the girl was dehydrated by the time she got to hospital. This is the only place I have worked. I feel that my lack of experience is to blame for not recognizing the seriousness of this pt's VS. Could someone please help me - how bad was it that this pt had a HR in the 130's for several hours? Apparently she was stabilized later that day, and off the O2. BTW, she has a DNR order. Any comments would be appreciated.

[jeromemdayao]

Well, you should have realized that very abnormal VS should have been reported immediately. Even if a patient is DNR you still need to know to what extent the DNR is to implored. Some put DNR but IV fluids etc... And even if your patient was DNR it is not an excuse not to attend to the pressing situation of the abnormally high VS, DNR only applies to your case, if the patient died(you wont resuscitate) but clearly, in your case the patient was still alive and due care should have been rendered. What you did is a clear example of would be negligence. Although there was an act of omission, there is still was no harm with the patient(as what you stated). This means that there aint no negligence since the two conditions did not exist altogether. It is also evident that with the kind of RR the patient could have lost some amount of insensible fluids thru the lungs. The tachycardia in the first place signaled that there is already some form of dehydration that should have been arrested, Was the patient at least conscious and oriented?

[Antikigirl, ASN, RN]

The biggest thing I would have advised, given I have working in very very simular sitations as your employ...GET THE MD on that phone, if you can't...then 9-11 call!

I don't tend to take chances with VS like you described, unless I have specific orders from an MD on things ordered to do before they go to the hospital (which for people with frequent bouts of probelms I had MD's write orders on what to do first, how long to wait, and parameters of VS and such..I had a patient that had very bad chronic chest pains, but it was actually GI pains that did radiate to her chest wall...after about 10 visits in 2 years, we had a protocol to do before going to the hospital). You may want to pursue that or suggest that!

And yes, a DNR is not "do nothing" but treat this person till death, then don't try to bring back (according to the orders on what you can and can't do in that case).

You will learn this as you go on, and I am sorry you are being investigated! Stick to your guns that that was your clinical choice in the matter, be truthful, and hopefully all will go well. Typically in these cases I refer to the LACK of protocol in these facilities for Emergencies...but be aware of that lack, and learn as much as you can to overcome those!

Better you be in trouble for doing too much in this situation than not enough...(and that isn't always the case..but that is another post all together).

[scattycarrot, BSN, RN]

I agree with jeromemdayao that despite your inexperience you should have been able to recognise abnormal vitals and respond appropriately. Now, the tachycardia is concerning but depending on the age of the child, they tend to run faster than adults anyway, especialy with a pyrexia of 38. Did you administer an antipyretic? Of concern to me also, would have been the RR of over 30 and resulting desaturation. This signals to me that the childs respitory effort was insufficient to meet her needs and that she could tire quickly, as kids tend to do. What was her respitory effort like? Do you mind if I ask you why you didn't call the MD? I do sympathise as it is sometimes a difficult call to make whether to call the MD on a nightshift or not. As TriageRN_34 asks do you have protocols in place for this sort of thing or do you use the MEWs charts in your facility? If not, than you might suggest the use of them to aviod situations like this as it gives you the 'evidence' (and confidence) to make that call. I don't usually support the use of such scoring systems but in LTC, I can see how they would be helpful.

Good luck and for what its worth, remember that we have all made judgement calls that in the cold light of day, we regret but the important thing is to learn from them.

[RunnerRN, BSN, RN]

I'd be less worried about the HR and more so regarding the decreased SpO2 and fever. Sounds like a raging pneumonia. Not knowing the pt's age and med hx, I can't really pass judgment on the HR and RR. Those would be pretty acceptable numbers for a 1 yr old, but not for a 9 year old. And yes, I think you should have recognized the severity of a low sat, even excepting the HR. Good luck.

[pepperann35]

I'd be less worried about the HR and more so regarding the decreased SpO2 and fever. Sounds like a raging pneumonia. Not knowing the pt's age and med hx, I can't really pass judgment on the HR and RR. Those would be pretty acceptable numbers for a 1 yr old, but not for a 9 year old. And yes, I think you should have recognized the severity of a low sat, even excepting the HR. Good luck.

Just the 02 stats would be enough to alarm me. Put on the 02, and call the Dr.!